"Not Medically Necessary": Helping America's Health Insurers Deny Coverage

Front-line experiences with denials

• Clinicians describe “peer-to-peer” reviews as gatekeeping by non-specialists (nurses, therapists, other specialties) who can block rehab or hospital care as “not medically necessary.”
• These calls are usually unpaid, but time spent fighting denials gets baked into higher visit/procedure rates.
• Some clinicians aggressively contest denials; others give up, leaving patients without services or with large bills.
• A former insurer call-center worker reports being undertrained, pressured to default to denial, and eventually just approving everything out of discomfort and confusion.

Is this “practicing medicine”?

• One side argues that deciding what is “medically necessary” is de facto medical practice, should require appropriate specialty credentials, and ought to carry malpractice-style liability.
• Others state that, legally, insurers are only deciding what they’ll pay for, not what care a patient may receive; the doctor and patient can still proceed if they self-pay. Critics call this a legal fiction, as cost effectively blocks care.
• Several note that state rules vary on whether physicians must review denials; federal law is described as relatively weak or absent here.

System design, incentives, and blame

• Commenters emphasize misaligned incentives: for-profit insurers gain by denying or delaying, while providers may over-test, over-treat, or profit from owning equipment.
• Debate over where most waste lies:
  • One camp blames insurers and their denial machinery, prior auth hoops, and vertical integration (insurers buying provider groups).
  • Another points to providers’ high prices, overprescription, and administrative inefficiency as the main cost drivers.
• There is extended back-and-forth over how much insurer-driven administrative burden actually contributes to total costs, with no consensus.

Medicare Advantage and privatization

• Traditional Medicare plus Medigap is portrayed as more predictable and less adversarial; Medicare Advantage is seen as cheaper upfront but denial-heavy and highly profitable for insurers.
• Some argue private plans were supposed to be more efficient but now cost the government more per enrollee and rely heavily on utilization management.

Reform ideas and workarounds

• Proposals include: stronger penalties for wrongful denials, requiring same-specialty reviewers, banning non-physician determinations of “medical necessity,” breaking up vertically integrated “payvider” giants, and moving to single-payer or fully privatized models (sharp disagreement here).
• Technical efforts like standardized prior-authorization APIs are mentioned as partial, process-level improvements.
• Tactics to fight denials (HIPAA “hacks,” regulators, startups that automate appeals) are discussed; some success, some debunked, and many report exhaustion from the effort.